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Guidelines - Establishment of guidelines that cefazolin is cephalosporin of choice. Physicians contacted if orders deemed to be noncompliant.

Total purchases of cephalosporins decreased by $55,715 or 46.2% in first 12 months of program. Purchase costs for cephalosporins decreased from $0.921 per patient day to $0.519 (43.6%) per patient after the study period. Number of milligrams of cephalosporins used per patient day decreased from 398.16 to 178.77 (55.1%) while number of patient days decreased by 4.45%.

76 hours per month for pharmacist, 24 hours per month for ID fellows, 10 hours per month for 4 faculty

Restriction-creation of formulary restrictions for vancomycin and select aminoglycocides and cephalosporins, which would require obtaining ID approval for use. ID told not to reject requests but to use persuasion.

Combined savings from restricted antibiotics $2.61 per antibiotic day and $34,597 after formulary restrictions. 7.2% and 12.4% savings respectively from the pharmacy’s 1985 $18.45 average cost per antibiotic day and $199,003 average monthly expenditure. No significant changes in LOS or mortality for patients after restrictions.

Restriction - Eight IV antibiotics (amikacin, aztreonam, ceftazidime, ciprofloxacin, fluconazole, imipenem-cilastatin, ofloxacin, and ticarcillin-clavulanate, (aztreonam was added to list two months into intervention) previously needed approval, but enforcement of restrictions lax. All staff informed that ID approval needed for dispensement and that pharmacists needed to be informed in writing or by telephone. Enhanced enforcement included issuing warnings to pharmacists if restricted antibiotics dispensed without ID approval.

$82,544 reduction in restricted antimicrobials after 2 months, but $79,008 increase in cost of unrestricted. After aztreonam restricted, acquisition costs decreased from $53,496 per month to $10,115 per month after two months. Hospital reduced costs by $300,235 over nine-month period.

Streamlining - Patients on two or more empiric parenteral antibiotics identified by nursing unit pharmacist, results shared with ID physician, who then called prescribing physician to suggest alternative monotherapy.

Cases necessitating streamling decreased from 98.6% during first month to 54.4% during seventh month. Total cost savings of $38,920.95 during intervention period. Annual cost savings estimated to be $107,637 after adjusting for changes in improved prescribing practices.

Streamlining - Patients on two or more antibiotics identified by computer. After records review for redundant combinations, pharmacist would contact clinician to determine clinical indication and make recommendations for streamlining when appropriate.

71% of combinations investigated found to be inappropriate. Intervention projected to have $10,800 in cost savings and 584-day reduction in antibiotic combination days.

inpatient pharmacy computer system for identifying patients on >=2 antibiotics

Order form - Creation of an order form with preset dosing orders for clindamycin, cefazolin and metronidazole. Physicians still had option to choose own dosing schedule on the form.

Before intervention, incorrect dosing orders for clindamycin, cefazolin, and metronidazole were 90%, 60% and 75% patient days of therapy respectively. After implementation, nonrecommended dosing fell to under 6% of patient days. Savings amounted to $76,000 annually in drug costs.

Reduction in $370,069 in projected, annual cost associated with restricted antimicrobial use and an 11.6% reduction in doses of restricted antibiotics over one year. User satisfaction improved from 22% to 68% and from 13% to 69% among prescribers and pharmacists respectively.

Electronic Monitoring – randomized controlled trial of active monitoring by antimicrobial management team of all restricted antibiotic orders with a computer system compared to a group without the computer system to alert for inadequate antimicrobial therapy.

Team intervened in 16% of patient cases in intervention arm vs 8% in control arm and spent one hour less per day with the intervention arm. Hospital expenditures were $285,812 vs. $370,000 in control arm over 3 months. No significant difference in mortality. Clostridium difficile super infection NS/3 months.

Multidisciplinary - Three month randomized controlled trial of patients receiving parenteral antibiotics for three or more consecutive days. Intervention group received suggestion for antibiotics from ID and pharmacist. The control did not.

49% of intervention group received suggestions. Per patient antibiotics cost was $400 lower in intervention vs. control (p=0.05). Clinical outcomes similar for patients in both groups.

Multidisciplinary - Implementation of new restrictions in antibiotic formulary for broad-spectrum antibiotics and restrictions for antibiotics maximum daily dosage.

Average monthly antibiotics cost during 26-month, post-intervention period was $7,600 less than in 16-month pre-policy period (p<0.001). Therapies altered by ID 34.5% of cases during 26 month period. Antibiotic use per patient in similar DRG decreased by 24% (p=0.005) and cost decreased by 32% (p=0.004). In repiratory infections DRG average number of doses decreased by 33% and cost by 45% (p=0.05 and 0.04 respectively). Pt outcomes similar pre and post intervention.

Over 12 months, 52% of patients converted to oral equivalent of intravenous antibiotics initially prescribed. Average number of days of therapy for patients converted was 1.53 days shorter (3.3 +/-2.8 vs. 4.83+/-2.1) than those not converted (p<0.003). Cost savings for drug acquisition and LOS were $15,149.24 and $161,071.88 respectively. Over 12 months, 52% of patients converted to oral equivalent of intravenous antibiotics initially prescribed. Average number of days of therapy for patients converted was 1.53 days shorter (3.3 +/-2.8 vs. 4.83+/-2.1) than those not converted (p<0.003). Cost savings for drug acquisition and LOS were $15,149.24 and $161,071.88 respectively.

No difference in clinical courses, cure rates, survival, or resolution of CXR abnormality. Mean duration of therapy was 6.88 days in control vs. 7.3 days in intervention and frequencies of symptom improvement were 97% vs. 95% respectively. Patients in intervention had shorter hospital stays (7.3 vs. 9.71 days p=0.01) and lower total costs of care ($2,953 vs. $5,002) p<0.05). There was no difference in clinical courses, cure rates, survival, or resolution of CXR abnormality. Mean duration of therapy was 6.88 days in control vs. 7.3 days in intervention and frequencies of symptom improvement were 97% vs. 95% respectively. Patents in intervention had shorter hospital satys (7.3 vs. 9.71 days p=0.01) and lower total costs of care ($2,953 vs. $5,002) p<0.05).

Patients with known resistant infections randomized to a intervention consult vs. usual care. Interventional consult done by multidisciplinary team and made recommendations for appropriate therapies while also weighing economic factors of medication.

Median length of stay after randomization for control and intervention groups was 9.0 days and 5.7 days, respectively (3.3-day difference, p=0.0001). Physician acceptance of suggestions was 89%. Median patient charges for radiology, laboratory, pharmacy, and room were reduced by $4,404/intervention, and median hospital costs were reduced by $2,642/intervention.